Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case–control study in Bangladesh

Objectives: We estimated the effect of an Employer-Sponsored Health Insurance (ESHI) scheme on the utilization of healthcare from medically trained providers and reduction of out-of-pocket (OOP) expenditure by the ready-made garments (RMG) workers.

Design: We used a case-control study design with cross-sectional pre- and post-intervention surveys.

Settings: The study was conducted among workers of 7 purposively selected RMG factories in Shafipur, Gazipur of Bangladesh.

Participants: In total, 1,924 (480 from the insured and 482 from the uninsured, in each period) RMG workers were surveyed from insured and uninsured RMG factories respectively, in pre- (October 2013) and post-intervention periods (April 2015).

Interventions: We tested the effect of a pilot ESHI scheme which was implemented for 1 year.

Outcome measures: The outcome measures were the utilization of healthcare from medically trained providers and reduction of OOP expenditure by the RMG workers. We estimated difference-in-difference (DiD) and two-part model to measure the association between healthcare utilization, OOP payments and ESHI scheme membership while controlling for socioeconomic characteristics of the workers.

Results: The ESHI scheme increased the healthcare utilization (DiD=26.1; p<0.01) from medically trained providers among the insured workers compared to the uninsured workers. While accounting for covariates, the utilization significantly reduced by 18.4% (p<0.05). The DiD estimate showed that OOP expenditure was reduced for the insured workers compared to the uninsured workers while utilizing healthcare form the medically trained providers (DiD= -3,700 BDT) or any provider (DiD= -1,100.0 BDT), although not significant. The multiple two-part models also reported similar results.

Conclusion: The ESHI scheme significantly increased utilization of medically trained providers among RMG workers. However, it has no significant effect on OOP expenditure. It can be recommended that the educational intervention for improving healthcare-seeking behaviour of RMG workers may increase utilization of ESHI designated healthcare providers while keeping OOP payments low.